Negative Postoperative Behavioural Changes Research Articles

Development of a nomogram to predict negative postoperative behavioral changes based on a prospective cohort

BackgroundIt is believed that negative postoperative behavioral changes (NPOBC) is associated with negative perioperative outcomes in children. The importance of development of a predictive model of NPOBC was noted. This study aims to identify potential risk factors develop a nomogram to predict NPOBC on postoperative day 3 based on a prospective cohort.MethodsA prospective observational study was conducted on children(American Society of Anesthesiologists I ~ III) aged 2 ~ 12 years who underwent selective surgery under general anesthesia between September 2022 and February 2023. The patient’s clinical data were analyzed. The method of measuring NPOBC is with the The Posthospital Behaviour Questionnaire (PHBQ), and all of children remained hospitalized at the time of assessment. The enrolled patients were categorized into the NPOBC group and the non-NPOBC group according to if children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors and develop the nomogram to predict NPOBC. Internal validation was performed using the parametric bootstrapping method.ResultsOne hundred ninety-two patients were enrolled in the study, 44.8% (86/192 patients) of children developed NPOBC on postoperative day 3. Univariate and multivariate logistic regression analysis demonstrated that the Pediatric Anesthesia Behavior (PAB) score (OR: 1.23, 95%CI: 1.14–1.33), cerebral desaturation (OR: 1.16, 95%CI: 1.02–1.32), and postoperative pain score (OR: 1.07, 95%CI: 1.02–1.13) were independent predictors for NPOBC on postoperative day 3 (P < 0.05). They were used to develop the prediction model. The calibration curve demonstrated satisfied discrimination and calibration of the prediction model. The model presented with good discriminative ability (area under the receiver operating characteristic curve: 0.762 [95%CI: 0.691—0.833]). The decision curve analysis also revealed the great clinical utility of the nomogram.ConclusionBased on our prospective observational study, pre-anesthesia patients with higher PAB scores, presence of cerebral desaturation, and higher postoperative pain score were more likely to develop NPOBC on postoperative day 3. We established and validated a nomogram for predicting NPOBC, which could help assess patients individually, identify high-risk groups of NPOBC and improve patient prognosis.Trial registrationChinese Clinical Trial Registry, ChiCTR‐2,200,059,776. Registered 11 May 2022.

Incidence and risk factors associated with negative postoperative behavioral changes in children undergoing painless gastroscopy

ObjectiveTo investigate the incidence of and risk factors associated with negative postoperative behavioral changes (NPOBCs) in children undergoing painless gastroscopy.MethodsInclusion criteria: ASA I–II and outpatients aged 6–12 years undergoing painless gastroscopy. Exclusion criteria: history of surgery or anesthesia, children with developmental or intellectual abnormalities, refusal to participate, preoperative abdominal pain score > 3 points, history of chronic abdominal pain of > 3 months duration, and serious intraoperative complications. On the 1st, 14th, and 30th day after the gastroscopy, the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) was used to assess NPOBCs in children.ResultsA total of 1,670 children were included in this prospective observational cohort study. The incidence rates of NPOBCs were 14.13%, 4.55%, and 2.14% on the 1st, 14th, and 30th day after gastroscopy, respectively. The risk factors for the first day were female sex (OR 1.34, 95% CI 1.00–1.79), parental anxiety (OR 2.23, 95% CI 1.75–3.12), and severe anxiety in children (OR 2.83, 95% CI 1.96–4.07). The risk factors on the 14th day were parental anxiety (OR 3.71, 95% CI 2.19–6.29), a parental educational level above high school (OR 1.65, 95% CI 1.00–2.70), and severe anxiety in children (OR 11.87, 95% CI 5.85–24.07). The risk factors on the 30th day were female sex (OR 2.99, 95% CI 1.41–6.34), being an only child (OR 4.42, 95% CI 2.18–8.95), a parental educational level above high school (OR 2.66, 95% CI 1.27 NPOBCs 5.56), and severe anxiety in children (OR 6.84, 95% CI 2.84–16.49).ConclusionIn children undergoing painless gastroscopy, the incidence rates of NPOBCs on the 1st, 14th, and 30th day were 14.13%, 4.55%, and 2.14%, respectively. The risk factors for NPOBCs were severe anxiety in children, female sex, parental anxiety, and a parental educational level above high school. In particular, severe preoperative anxiety in children was a persistent risk factor for NPOBCs within 30 days.

Hypnosis as an alternative to general anaesthesia for paediatric superficial surgery: a randomised controlled trial

BackgroundReducing perioperative anxiety and controlling pain in children are essential to optimise recovery and outcomes for both children and their parents. By acting on sensory and affective modulation of anxiety and pain, hypnosis is widely used in medical care, especially in anaesthesia. This randomised controlled clinical trial was designed to compare general anaesthesia and intraoperative hypnosis support for perioperative management of children undergoing superficial surgery. MethodsChildren aged 7–16 yr scheduled for day-case superficial surgery were included and randomly assigned to one of the following two groups: general anaesthesia group or hypnosis group. The primary outcome was length of hospital stay. Child and parent anxiety, child pain, and the occurrence of postoperative negative behavioural changes were also evaluated. ResultsSixty children of mean age 10.3 (standard deviation: 2.6) yr were enrolled in the study. Hypnosis was successful in all but one case. The median (25th–75th percentile) length of hospital stay was shorter in the hypnosis group (120 [95–145] vs 240.5 [218–275] min; P<0.001). The general anaesthesia group was associated with a greater incidence of high levels of preoperative anxiety in children (30 vs 11%; P=0.001) and parents (55 vs 30%; P=0.05). Pain scores did not differ between groups. No negative postoperative behavioural changes were reported. ConclusionsIn children aged 7–16 yr, hypnosis appears to be feasible and accepted. The quality of the perioperative experience and the rapid recovery support the use of hypnosis as an effective and safe alternative to general anaesthesia for paediatric superficial surgery. Clinical trial registrationNCT02505880.

Which is good for pre-operative anxiety? Midazolam, video games or teaching with cartoons: A randomised trial.

Pre-operative anxiety in children has been associated with adverse clinical outcomes such as difficulty in anaesthesia induction, emergence delirium and negative postoperative behavioural changes. Therefore, pre-operative anxiety should be alleviated in both children and clinicians. We investigated the effect on pre-operative anxiety of premedication with midazolam, playing video games or watching a cartoon about anaesthesia. A prospective randomised trial. Single-centre study performed between August 2018 and June 2019. We enrolled 138 patients aged 5 to 8 years undergoing elective surgery. After evaluating baseline (T0) anxiety levels using the modified Yale Pre-operative Anxiety Scale (mYPAS) in the pre-operative holding area, 0.5 mg kg-1 oral midazolam was given to Group M, a tablet with videogame applications was given to Group T, and Group S watched the cartoon 'Şüko Is Being Operated'. mYPAS values were recorded a further three times: 20 min after the intervention (T1), while entering the operating room (T2), and during mask induction of anaesthesia (T3). The primary endpoint was the change in children's anxiety levels from baseline. The secondary endpoint was cooperation during mask induction. The baseline mYPAS scores were comparable (40.7, 42.6 and 40.7 in groups M, S and T respectively). The mean mYPAS scores at T1 were 32.6, 34.7, 26.8 and at T2 were 38.6, 42.7, 35 in groups M, S and T, respectively. There were significant differences between groups S and T at T1 and T2 (P < 0.001, P = 0.010). A significant decrease was found in Group T compared with both groups M and S from T0 to T1 (P = 0.002). mYPAS values at T3 were 38.3, 43.7, 39.5 in groups M, S and T, respectively, with no difference between the groups (P = 0.224). Mask acceptance scores were similar in all groups (P = 0.912). The passive teaching technique of watching a video for reducing anxiety levels was not effective. However, active distraction with videogames was found to be a valuable method to reduce pre-operative anxiety. ClinicalTrials.gov identifier: NCT03530670.

Cerebral NIRS—How low is low?

Cerebral near-infrared spectroscopy (NIRS), a noninvasive means of monitoring cerebral oxygenation, is inferred to reflect the balance between tissue oxygen delivery and consumption. Although some studies have demonstrated an association between cerebral NIRS and intellectual outcome in special populations, such as those with hypoplastic left heart syndrome (J Thorac Cardiovasc Surg 2016;151:1358-66), questions remain regarding broader applicability. Although frequently used during anesthesia for congenital heart surgery, use in a broader surgical population is not established, including in adult patients (Anesth Analg 2012;115:1373-83). With this in mind, the report by Gómez-Pesquera et al in this volume of The Journal is intriguing, but raises as many questions as it answers. This was an observational study of 198 children undergoing non-cardiac surgery. A validated questionnaire was administered on post-operative day 7, and an association was found with negative behaviors (including anxiety, eating disturbances, and apathy/withdrawal) for every 1% decrease from baseline in cerebral oxygenation by NIRS. A similar association was found when comparing the degree of preoperative anxiety as measured by the modified Yale Preoperative Anxiety Scale with post-operative behaviors. General anesthesia is, of course, unavoidable at times, but these findings should prompt further inquiry into the consequences of anesthetic exposure to the developing brain. This study does not address the severity of behavioral changes nor whether there are any long-term consequences, because the only reported outcome is a survey at 7 days. And although it challenges the notion of extrapolating adult thresholds to children, it remains difficult to assess to what degree of decrement is worrisome, since, unlike systemic oxygen saturation, there are no hard and fast cutoffs for cerebral NIRS. All reports are expressed as change from baseline, with a wide biologic variability in that baseline. An additional concern is whether changing management in response to cerebral NIRS changes outcomes, as evidenced by a growing body of literature in neonates (Curr Opin Pediatr 2018;30:209-15) (Acta Paediatr 2019;108:275-81). So, although premature to advocate for specific indications or thresholds for use of cerebral NIRS during pediatric surgery, this report should encourage further investigations into the nature and consequences of anesthesia and the most effective monitoring of the developing brain. Article page 207▶ Cerebral Oxygen Saturation and Negative Postoperative Behavioral Changes in Pediatric Surgery: A Prospective Observational StudyThe Journal of PediatricsVol. 208PreviewTo evaluate if an intraoperative cerebral regional oxygen saturation (crSO2) decrease, less pronounced than 20% below baseline (the current threshold believed to be associated with cognitive dysfunction in adults), is associated with negative postoperative behavioral changes (NPOBC) in the pediatric population after noncardiac surgeries. Full-Text PDF

Dexmedetomidine for the prevention of emergence delirium and postoperative behavioral changes in pediatric patients with sevoflurane anesthesia: a double-blind, randomized trial.

ObjectivesEmergence delirium (ED) is a common neurologic complication that can not only distress children and their families in the early postanesthetic period, but can also have adverse effects on children in the long-term. This study aimed to investigate the effects of single-dose dexmedetomidine on ED in children with sevoflurane anesthesia and to observe postoperative behavioral changes through long-term follow-up.MethodsPatients aged 2–7 years, American Society of Anesthesiologists class (ASA) I or II, scheduled for tonsillectomy with and without adenoidectomy were randomized to receive dexmedetomidine 0.5 μg/kg (Group D) or volume-matched normal saline (Group C) over 10 minutes after induction of anesthesia. The primary outcome was the incidence of ED within 30 minutes after extubation. Other outcomes were the incidence of pain, extubation time, post-anesthesia care unit (PACU) length of stay after extubation, adverse events, and the incidence of negative postoperative behavioral changes (NPOBCs).ResultsNinety children completed the study. Compared with the control group (Group C), dexmedetomidine decreased the incidence of ED (31.1% vs 53.3%; P=0.033) and pain (28.9% vs 57.8%; P=0.006), but it prolonged extubation time (P⩽0.001). PACU length of stay after extubation and the percentage of adverse events were similar between groups. The incidence of NPOBCs in Group D was significantly lower at 1 and 7 days after discharge (33.3% vs 60.0%; P=0.011% and 24.4% vs 46.7%; P=0.028, respectively) than it was in Group C, but no significant difference was found at the 30th day.ConclusionDexmedetomidine 0.5 μg/kg reduced the incidence of ED after sevoflurane anesthesia and might be used to prevent NPOBCs.Clinical trials registrationChiCTR1800016828.

Cerebral Oxygen Saturation and Negative Postoperative Behavioral Changes in Pediatric Surgery: A Prospective Observational Study

To evaluate if an intraoperative cerebral regional oxygen saturation (crSO2) decrease, less pronounced than 20% below baseline (the current threshold believed to be associated with cognitive dysfunction in adults), is associated with negative postoperative behavioral changes (NPOBC) in the pediatric population after noncardiac surgeries. A prospective observational study was conducted with 198 children aged 2-12years old scheduled for noncardiac procedures under general anesthesia. Intraoperatively, crSO2 was monitored with a cerebral oximeter. On postoperative day 7, the Post-Hospital Behavior Questionnaire was used to diagnose NPOBC. The incidence of NPOBC was 38.8%. Logistic regression analysis revealed that with every 1% reduction of crSO2 from the baseline value, the odds of developing NPOBC were 1.199 higher. Likewise, preoperative anxiety (OR 2.832, P=.006), duration of surgery (OR 1.026, P<.0001), and being between the ages of 2 and 3years (OR 2.604, P=.048) were associated with NPOBC incidence. The multivariable logistic regression model receiver operating characteristic curve showed an area under the curve (95% CI)=0.820 (0.759-0.881). During noncardiac surgeries in the pediatric population, an intraoperative decrease in crSO2 less pronounced than 20% from the baseline value is associated with negative postoperative behavior changes on postoperative day 7. The long-term implications remain to be determined, but this supports attention to crSO2 during noncardiac surgeries.

Premedication and Induction of Anaesthesia in paediatric patients.

Perioperative anxiety has been associated with adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems and new-onset enuresis. Predictors of preoperative anxiety have been identified, and these include, among other factors, the age and temperament of the child. Any plan for anaesthetic induction in a child must take into account these factors. The anaesthetic plan must be individualised for special situations, for example, the child with behavioural disorder or at risk of aspiration. This article details the pharmacological and nonpharmacological methods to minimise preoperative anxiety and the techniques of anaesthetic induction in infants and children undergoing surgery. The benefits and limitations of inhalational and intravenous induction and the current status of rapid sequence induction in children are discussed. MEDLINE database was searched for this narrative review using the keywords including preoperative anxiety, child, premedication, paediatric and anaesthetic induction. Search was restricted to articles in English, but without any publication date restrictions.

Postoperative behavioral changes in Chinese children undergoing hypospadias repair surgery: A prospective cohort study.

The perioperative period can be psychologically challenging, and children may exhibit behavioral changes following surgical anesthesia. It is unknown whether children in China have additional risk factors associated with negative behavioral changes. The aim of this study was to investigate the incidence of behavioral changes in children after hypospadias repair surgery and to identify potential risk factors associated with negative behavioral changes. A prospective cohort of 177 children aged 2-12years scheduled for hypospadias repair surgery from 2016 to 2017 was studied. The primary outcome was the incidence of behavioral changes on postoperative days 14 and 30 evaluated with the Post-Hospitalization Behavioral Questionnaire. Data collected included demographic data, anesthesia details, procedure details, admission details, child anxiety, child temperament, pain, and emergence delirium. Multivariable logistic regression was used to identify risk factors associated with postoperative negative behavioral changes. A total of 60.5% (107/177) of children exhibited negative postoperative behavioral changes on day 14 and 46.5% (79/170) exhibited changes on day 30 after the surgery. Approximately 2.3% (4/177) and 2.4% (4/170) of children showed improved behavior on postoperative days 14 and 30, respectively. The frequency of temper tantrums changed the most. The logistic regression results suggested that a younger age (odds ratio: 0.86; 95% confidence interval 0.76-0.96), emotional temperament (odds ratio: 1.1; 95% confidence interval 1.0-1.2) and maternal education (odds ratio: 2.2; 95% confidence interval 1.1-4.5) were associated with negative postoperative behavioral changes on day 14. On day 30, a younger age (odds ratio: 0.87; 95% confidence interval 0.77 to 0.98) was the only factor associated with negative postoperative behavioral changes. For children undergoing hypospadias repair surgery in our institution, approximately three in five showed postoperative behavioral changes. In addition to a younger age and a higher maternal education, an emotional temperament is associated with a high incidence of negative postoperative behavioral changes.

Negative postoperative behaviors in children under general anesthesia

Background Children, elected to major surgeries under general anesthesia, experience tremendous stress during perioperative period, and the stress may be associated with negative postoperative behavioral changes(NPOBC), such as nightmares, enuresis, temper tantrum, etc, which may affect both emotional and cognitive development in these children. Objective To promote the awareness of NPOBC, meanwhile, to probe risk factors for its intervention to reduce the incidence of NPOBC and improve the prognosis of these children. Content Clinical trials reveal multiple potential risk factors for NPOBC, including young ages ( 4 d) in hospital, etc. These abnormal behaviors could relate to toxic effects of anesthetics on neuronal development, differentiation, connections, and apoptosis. Moreover, neuroinflammation initiated during surgery and the release of stress hormones in perioperative period could also contribute to these behaviors. Several strategies were implemented in several investigations, including administration of benzodiazepine antidepressant drugs or 2-adrenoceptor agonists, enhancement of support from family, and alteration of anesthetic procedure, etc. However, none of these interventions has convincing effectiveness. Trend There still lacks causal links between the risk factors mentioned above and the incidence of NPOBC. Additionally, the molecular, cellular, and circuit mechanisms underlying NPOBC require further multidisciplinary investigations, which may eventually provide avenues for the treatment and intervention of these behaviors. Key words: Children; Postoperative behavioral changes; Anesthesia, general

Are postoperative behavioural changes after adenotonsillectomy in children influenced by the type of anaesthesia?: A randomised clinical study.

Negative postoperative behavioural changes (NPOBCs) are very frequent in children after surgery and general anaesthesia. If they persist, emotional and cognitive development may be affected significantly. To assess whether the choice of different anaesthetic techniques for adenotonsillectomy may impact upon the incidence of NPOBC in repeated measurements. A randomised, controlled, parallel-group trial. University Hospital Split, Croatia. Sixty-four children (aged 6 to 12 years, ASA 1 to 2) undergoing adenotonsillectomy assigned into one of two groups: sevoflurane (S) (n = 32) or total intravenous anaesthesia (TIVA) (n = 32). Permuted-block randomisation with random block sizes of 4, 6 and 8, administering anaesthesia, and evaluation of NPOBC with the Post Hospitalization Behavior Questionnaire (PHBQ: 27 items describing six subscales). The PHBQ was filled out by parents at postoperative days (POD) 1, 3, 7 and 14, and 6 months after surgery. Differences in numbers of NPOBCs between two anaesthesia techniques, and NPOBC analysis by subscales. The prevalence of at least one NPOBC after surgery ranged from a maximum of 80% [95% confidence interval (CI) 71 to 90%] on POD 1 to a minimum of 43% (95% CI 31 to 56%) 6 months after surgery. Absolute risk reduction for at least one NPOBC in the TIVA group compared with the S group increased from 0.24 on POD 1 to 0.55 6 months after surgery. The number of NPOBCs was also lower in the TIVA group [median 5, interquartile range (IQR) 2 to 10] than in the S group (median 22, IQR 10 to 32) (P < 0.001). The overall number of NPOBCs within PHBQ subscales was significantly lower in the TIVA group than in the S group. The largest difference in the number of NPOBCs between groups was observed for the separation anxiety subscale (mean 5, 95% CI 1 to 9; P < 0.001) followed by the general anxiety subscale (mean 4, 95% CI 3 to 5; P < 0.001) and apathy/withdrawal subscale (mean 3, 95% CI 1 to 5; P < 0.001). The prevalence of NPOBC after elective adenotonsillectomy in 6 to 12-year-old children was very high (80%). The choice of anaesthetic technique for adenotonsillectomy in children influenced the incidence and type of NPOBC. Sevoflurane/nitrous oxide anaesthesia was associated with more frequent and prolonged NPOBCs than TIVA, especially in the separation anxiety, general anxiety and withdrawal/apathy subscales.

Are Our Children All Right?

Are Our Children All Right?

Hypnotic depth and the incidence of emergence agitation and negative postoperative behavioral changes

Emergence agitation (EA) and negative postoperative behavioral changes (NPOBC) are common in children, although the etiology remains unclear. We investigated whether longer times under deep hypnosis as measured by Bispectral Index (BIS) monitoring would positively correlate with a greater incidence of EA in the PACU and a greater occurrence of NPOBC in children after discharge. We enrolled 400 children, 1-12 years old, scheduled for dental procedures under general anesthesia. All children were induced with high concentration sevoflurane, and BIS monitoring was continuous from induction through recovery in the PACU. A BIS reading <45 was considered deep hypnosis. The presence of EA was assessed in the PACU using the Pediatric Anesthesia Emergence Delirium scale. NPOBC were assessed using the Post-Hospital Behavior Questionnaire, completed by parents 3-5 days postoperatively. Data were analyzed using logistic regression, with a P < 0.05 considered statistically significant. The incidence of EA was 27% (99/369), and the incidence of NPOBC was 8.8% (28/318). No significant differences in the incidence of EA or NPOBC were seen with respect to length of time under deep hypnosis as measured by a BIS value of <45. Our data revealed no significant correlation between the length of time under deep hypnosis (BIS < 45) and the incidence of EA or NPOBC. Within this population, these behavioral disturbances do not appear to be related to the length of time under a deep hypnotic state as measured by the BIS.

Distress during the induction of anesthesia and postoperative behavioral outcomes.

We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.

Distress During the Induction of Anesthesia and Postoperative Behavioral Outcomes

We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process.Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. Implications: Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes. (Anesth Analg 1999;88:1042-7)